This document describes the Fothergill's Operation procedure for uterine prolapse. The key steps are: 1. Amputating the elongated cervix while preserving menstrual function. 2. Approximating the cardinal ligaments in front of the cervical stump using a Fothergill stitch to support the uterus. 3. Repairing any enterocele or cystocele. The operation is indicated for 2nd or 3rd degree prolapse with vaginal wall defects. Complications can include hemorrhage, cervical stenosis, recurrence of prolapse, and bladder or fistula injuries. A modification by Shirodkar involves cutting and crossing the uterosacral ligaments in

1. Fothergill’s Operation
DR SHIVAMURTHY H M
PROF IN OBG .
SNMC BAGALKOT , KARNATAKA .
INDIA

2. Objectives
1. To ampuatate the Portiovaginalis of the
cervix only when there is elongated.
2. Approximation of the cardinal ligaments in
front of the cervical stump Fothergil stitch.
3. Repair of enterocele.
4 Cystocele repair

3. Indication
• It is done in 2nd and 3rd degree uterine
prolapse with cystocele,
• Supravaginal elongation of the cervix in a
women desirous of retaining her mentrual
function.

4. Contraindications
• Suspected pregnancy
• Pelvic Infection .
• Suspected malignancy of genital tract

5. Disadavantages
• Cervical incompetence and habitual
abortion
• Preterm labor and precipitate labor
• Excessive fibrosis may lead to cervical
stenosis and dystocia during labor.
• Dysparunia
• Increased incidence of caesarean section.

6. Prerequisites:
• Blood compatible with the patients blood
should be ready
• Cervical exfoliative cytology.
• Urine routine and microscopy.

7. Steps of Operation
• The patient is put in dorsal position,legs
supported, buttocks at the edge of the table .
• Perineum is painted and draped and bladder
catheterised.

8. Steps of Operation
Exposure of the operative field and do diagnostic
currettage:
• A sims specullum is placed in the vagina,the
anterior lip of the cervix is grasped with a
tenaculum, uterocervical length is measured,cervix
is dilated to a 10mm Hegars dilator ,uterus curetted
and then the cervix is pulled down.
• The vaginal wall covering the cervix is elevated in
the midline between two allis clamps.

9. Initial incision on the anterior vaginal wall:
• Marking Silk sutures are placed in the vaginal
wall on either side of the cervix at a point
adjacent to the attachment of cardinal ligaments.
• a transverse incision is cut through the vaginal
wall into the areolar tissue space between cervix
and the vaginal wall.

10. Fothergills Points
The vaginal mucosa is grasped with 4 Allis forceps
at four fothergills points,
1. Just below the urethral orifice
2. Behind the cervix in the posterior fornix in the
midline about the lower level of uterine isthmus.
3 Two lateral points which (when approximated to
each other in front of the cervix) would make
the vaginal vault of the right size.
An incision is made in the vaginal mucosa
joining these four points.

11. 6.Separation of the bladder from the cervix:
• Cervix held in downward traction and lower
margin of the bladder is elevated with allis
clamp.
• Fascial attachments of bladder to the cervix
is cut.
• Proper cleavage between bladder and cervix
is identified, bladder is advanced above the
cervix with gauze covered finger.
.

12. FOTHERGILLS KEY SUTURE
(for the anterior lip)
• The suture enters the vaginal skin at the level of
Fothergill’s lateral point and transfixes the cut
cardinal ligament pedicles.
• The needle next passes from without inwards
through the full thickness of the ant cervical muscle
near midline at 12 o’clock.
• The needle isnow repassed from within outwards
and through cardinal ligament pedicle of the
opposite side and finally out at opposite lateral
fothergill point.
• These two are tied together in anterior midline.

13. Complete covering of the cervix.
• The lateral aspect of the raw cervical
stump may be closed by interrupted
sutures
.Sounding of the cervix and packing of the
vagina

14. Problems with Fothergills operation :
• Improper dilation of cervix makes fothergills
stitch difficult.
• If pedicles of cardinal ligaments are short it is
difficult to fix it anteriorly at internal os.
• The cardinal ligaments should be doubly ligated.

15. Complications
• Primary hemmorrhage.
• Secondary hemorrhage from cervical stump
after ten to twelve days.
• Post surgery cervical stenosis
• Recurrence of prolapse
• Bladder injury
• Vesico vaginal fistula
• UTI
• Urinary stress incontinence from overcorrection
of cystocele
• Perineal abscess
• Rectovaginal fistula

16. Shirodkars modification of Fothergills
operation
• Indication-same as fothergills but without supravaginal
elongation of cervix.
• Steps- A circular incision is made all around the cervix
as for anterior colporrhaphy. Posterior peritoneum is
opened .
• Anterior colporrhaphy is done.
• Uterosacrals and adjacent part of cardinal ligaments are
cut ligated and crossed in front of the cervix and fixed
by nonabsorbable sutures.
• Rest of the ant vaginal wall is closed.

17. The end